Effectiveness of Virtual Care Team Guided Management of Hospitalized Patients with HFrEF by Ethnicity

Abstract

Background: The Implementation of Medical Therapy in Hospitalized Patients with Heart Failure with Reduced Ejection Fraction (IMPLEMENT-HF) study demonstrated that a virtual team-based care strategy was safe and improved prescription of guideline-directed medical therapy (GDMT) in hospitalized patients with heart failure and reduced ejection fraction (HFrEF). We evaluated differences in efficacy and safety outcomes by ethnicity in IMPLEMENT-HF.

Methods: IMPLEMENT-HF evaluated a provider-facing virtual team-based care strategy versus usual care in hospitalized patients with HFrEF from October 2021 to June 2022. The primary outcome was change in a GDMT optimization score from hospital admission to discharge, with positive changes reflecting net optimization. In this post-hoc analysis, we assessed heterogeneity in treatment effects by ethnicity (Hispanic vs. non-Hispanic). Outcomes included prespecified primary and secondary effectiveness outcomes and adjudicated safety events.

Results: Of 808 screened patient admissions, 252 (31%) from 198 unique patients met inclusion criteria. Hispanic patients (n = 43) were more likely to have diabetes and end-stage kidney disease than non-Hispanics; 70% spoke Spanish as a primary language. GDMT optimization score was lower among Hispanic versus non-Hispanic patients (-0.44; 95% CI -1.88 to 0.99 vs. +1.62, 95% CI +1.02 to +2.21; P value of interaction by ethnicity = .002). Allocation to the virtual care team intervention versus usual care increased the proportion of patients experiencing >1 new initiation or dose up-titration among non-Hispanic patients but did not among Hispanic patients (absolute difference non-Hispanic vs. Hispanic: +31% vs. -19%; P value of interaction = .003). Similar trends were seen among individual HF therapy and for the proportion of patients with optimization score >0 (absolute difference non-Hispanic vs. Hispanic: +29% vs. -20%; P value of interaction = .005). Safety outcomes were similar among Hispanic and non-Hispanic patients.

Conclusion: A provider-facing, virtual care team-guided strategy for HFrEF GDMT optimization was less effective in Hispanic patients. Efforts to identify and reduce bias and equity assessments in implementation studies are needed.

Keywords: Implementation science; disparities of care; equity; heart failure with reduced ejection fraction.